A recent AHA presentation offered data that showed an overwhelming amount of patients would prefer to take a pill or drink tea rather than exercise to lower their BP. This begs the questions: How much does drinking tea lower BP? Does exercise help those with primary HTN or resistant HTN who are already on medication? Finally, how do we get our patients to exercise?Guest: Robert A. Baldor, MD, FAAFP

Transcript

Dr. Frank Domino:
Gary's a 58-year-old male in your practice, and he presents today to discuss his hypertension. He heard a recent report on the news that all he has to do is drink tea to control his blood pressure, and wants to know what you think. Hi, this is Frank Domino. Joining me today on Frankly Speaking About Family Medicine is Robert Baldor, Professor and Senior Vice-Chair in the Department of Family Medicine and Community Health at the University of Massachusetts Medical School. Thanks for bringing this forward, Bob.

Robert A. Baldor, MD, FAAFP:
Thanks, Frank. Glad to be here. Probably what he's referring to was a recent study that was presented at the American Heart Association meeting, where a researcher looked at a survey. They had about 1,200 adults recruited online, another 100 patients that were attending an outpatient clinic in to complete the survey, most were young, under 45 years of age, and most had high blood pressure. They asked them the question, they said, "Imagine you have high blood pressure, and would you be willing to adopt any of these four treatments?" And the treatments were to gain an extra month, extra year, or extra five years of life. Really fascinating survey to look at this. The treatments proposed: A daily cup of tea, exercise, taking pills, or monthly semi-annual injections. And what do you think they found?
Dr. Frank Domino:
Well, people like to do the least, so I'm guessing... They wanted to take a cup of tea.
Robert A. Baldor, MD, FAAFP:
Yeah, it's fascinating. In my practice it's, "Isn't there a pill for that?" The results showed that taking a pill or drinking a daily cup of tea were the preferred treatment, although some were unwilling to do anything, interestingly enough. But 96% said that they would take a pill if it would get them an extra five years. 96% would drink tea for an extra five years. Interestingly, 93% would exercise.
Dr. Frank Domino:
Was that 93%?
Robert A. Baldor, MD, FAAFP:
93% actually said that they would exercise for an extra five years. But the headlines were taking the tea.

Dr. Frank Domino:
I bet that's what they said, but I'm not convinced that's what they do.

Robert A. Baldor, MD, FAAFP:
Well, that's a different piece of this. Then, by the way, taking a shot was the least favorable, although 88% would opt for an injection every month if it gave them an extra five years. Interesting data on what preferences that younger folks have.
Dr. Frank Domino:
Bob, drinking tea, exercise, we have good data. We discussed taking pills a lot. What's the data on drinking tea? Is it any kind of tea or what?
Robert A. Baldor, MD, FAAFP:
Yeah. Tea's been put out there for a long time as being beneficial and helpful for your health, and you look at a lot of these studies, it's like, "Well, is it because it's displacing something else or is there benefit or not?" So I always go back to this Cochrane Review, which was done a couple of years ago where they really looked at green and black tea for the primary prevention of cardiovascular disease. And they did find a little bit of a benefit in lowering blood pressure. Black tea would lower your systolic blood pressure by 1.8 millimeters, and your diastolic by about one as well. So maybe two millimeters, one millimeter reduction from black tea. I don't like black tea myself, I prefer the green tea. And so, green tea, was it any better? Yeah, green tea seemed to lower your systolic blood pressure by about three points, and the diastolic, again, by about three. So there is some evidence for efficacy with drinking tea. However, they talked about the fact that this is really limited evidence. Most of these studies were very small in nature and were observational. And it's hard to know what to make of these observational studies, but there appears to be some very minor benefit from drinking tea; green tea perhaps a little better than black tea.

Dr. Frank Domino:
So that's a great example of statistically significant finding that's probably clinically not relevant. Because if you're two or three millimeters of mercury high, many of us don't necessarily jump on the diagnosis or consider it a therapeutic benefit, to get a two or three millimeter reduction in systolic or diastolic. All right, well, so that's tea. We have limited data that it might help a bit. What do we know about exercise?

Robert A. Baldor, MD, FAAFP:
Well, exercise, we actually have increased, more data on that. It actually goes back to some studies that were actually done here back 2003, these studies were done. And they looked at how much exercise is required to reduce blood pressure in folks with hypertension, and it was great. They showed that exercise can lower systolic blood pressure by 12, diastolic by 6. Now, those are significant lowerings...
Dr. Frank Domino:
Those are insignificant.

Robert A. Baldor, MD, FAAFP:
In your numbers. I'll take that. Well, then the question, what they looked at was, how much exercise? This is really important 'cause if I can do that with as little exercise as possible, maybe I'll do that. What they found was the maximum benefit was for those who exercised 60 to 90 minutes a week. If you go above 90 minutes a week, they didn't really see much of a benefit from that. Less than 60 minutes a week was still beneficial, but not as much. So to get that reduction of the 12 over 6, that's really what people had to be doing. And then, it was interesting, a recent study was just also published here in looking at exercise in folks with resistant hypertension. So that was for primary treatment, now we're looking at folks with resistant hypertension. Resistant hypertension is those who are on three medications and still having trouble with control. The question is, if you add exercise onto people who are taking those pills already, can that be helpful? And it actually showed a reduction there as well, not quite as much as in the primary group. These are folks, mind you, that have resistant hypertension. But they showed a significant decrease of about six millimeters in systolic and three in the diastolic. So it even has benefit for people who have resistant hypertension on medications already.

Dr. Frank Domino:
All right. So tea, maybe a tiny bit of benefit, probably not clinically significant. Exercise, 60 to 90 minutes sounds like where we should be going for most of our patients, even those with resistant hypertension. Bob, I love prescribing exercise, but how do you help patients exercise 60 to 90 minutes a week?
Robert A. Baldor, MD, FAAFP:
Yeah, and that's a great question. And I think we've talked a lot about motivational interviewing, and how do we actually motivate people to make behavioral changes, and we have to get better at those skills, they're not that hard to do. And I think it's a little bit trying to talk to people about the benefits of some behavioral change versus taking a medication. Now people like to have you prescribe something. So prescribe exercise, you can write out an exercise prescription, and I will do this. I'll actually still get out my old prescription pad, although I bet there's probably an exercise prescription in my EHR that I don't use. But I like the idea of sitting down with them with a prescription pad, putting down and talking with them, "Well, what would you like to do for exercise?" 'Cause it's not necessarily that they have to get on a treadmill, maybe it's swimming, maybe it's walking, maybe it's running. What would they like to do for an exercise and, "When could you do this during the day and how many times?"

I would write this out like I would a medication. So you're saying, "Here's this drug. You're gonna take it once a day and you're gonna take it for three... So exercise... You're gonna go for a walk and you're going to do it for 20 minutes daily, or you're gonna do it 30 minutes, three times a week." Actually write it out. But part of this is working with a patient around what is the exercise that they can do, what fits in with their lifestyle, "Okay, you're gonna do this at noon time. Rather than having lunch, you're gonna go out and walk," or whatever, and how many times a day a week. And you want it to add up to 60 to 90 minutes a week. And I always shoot for the 90 minutes a week, because I figure if you shoot for the high-end and they miss a little, they'll hopefully hit the 60. And it is fascinating that that little amount of exercise shows a benefit.

Dr. Frank Domino:
Yeah, these are great, and there's just some data out there that really shows benefit with this. What I like about my Smart Watch is, it'll buzz if I've been sitting too long, and it'll say, "Hey, get up and walk," basically. I also have in here a targeted number of steps per day that I want to do at 10,000. And when I hit that, it buzzes and it flashes; those are just little positive reinforcements. And having this on my wrist actually reminds me of the fact that fitness and moving is part of my lifestyle. Again, those are reminders and that helps people as well. And again, there's some data beginning to show benefit from smart technologies.

Robert A. Baldor, MD, FAAFP:
Bob, thanks so much. Treating hypertension is a challenge that we all face, and this is really wonderful data that shows you can treat it with fairly small amount of exercise. Practice pointer, 60 to 90 minutes of aerobic exercise per week will significantly lower elevated systolic and diastolic blood pressure. Join us next time when we discuss the role of the digital rectal exam as part of the screening process for prostate cancer, and visit us at pri-med.com to stay current on many primary care topics.

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